The myth of tobacco/nicotine’s uniqueness

Brad Rodu and I just finished an overview paper about THR (which we expect will appear in a journal fairly soon). In it we mention that there are a few legitimate debates about THR that get very little coverage. A few of us who work in THR do discuss these. But since most of the discourse on THR is dominated by anti-THR lies, and thus most of the public “debate” is just attempts to debunk the blatant lies, it is very difficult to have a conversation about the genuine questions.

One of the legitimate debates is about whether low-risk tobacco/nicotine products should just be treated as normal consumer products, given that they are no more hazardous than many such products. If not, where on the spectrum of product control should they should fall? That spectrum ranges from normal consumer products that can affect health (like food or most items you can hold in your hand; there is quality-assurance regulation, but little more), to definitely dangerous but still easily obtained products (like basic medicines or ladders; to these we add warning labels and mandatory safety features), to substantially dangerous but legal products (like cigarettes or cars: to which we add substantial restrictions and other regulations), and on to restricted products (like prescription-only or banned drugs).

(Note: There is a case to be made that those items on this list that can hurt others, like cars, are the only ones that should be subject to anything other than quality control and warnings. The argument is that people should be free to make their own decisions about accepting their own risk, and so only those products with clear external risks should be actively controlled. I am not trying to address this normative question here, and am simply working from the reality on the ground that some products are regulated to protect people from themselves.)

Two articles in today’s New York Times very nicely illustrate this question. The first concerns an “energy drink” company that is being sued over the death of a teenager who died of heart failure after consuming the product. The question at issue is apparently whether the caffeine in the drink caused her death. As I have written about extensively at my EP-ology blog, the levels of caffeine in these drinks is no more than is available from coffee, and often is no more than the modest quantities in Coke or other popular sodas. There are other active ingredients in the energy drinks (which are really stimulant drinks, though the sugar does provide energy too), but since the focus is always on the caffeine, I will stick with that for now.

The claim is that the caffeine triggered a fatal cardiac event. But if smoke-free tobacco/nicotine really poses 1/100th the risk of smoking (or 1/200th or 1/50th, rather than zero risk), almost all the risk seems to come from the risk to the cardiovascular system of consuming a mild stimulant (this was the analysis of our 2006 analysis that is the source for the “99% less harmful” conventional wisdom). The major concern is the accumulated long-term effect, though there might be the occasional triggering effect for serious conditions that were not caused by the consumption. In the energy drink case, the teen is said to have had a structural heart defect that was a cause of her death, and this seems to be the defense in the lawsuit. But this would not actually rule out that the stimulants in the drink also were a cause, triggering the event (in legal arguments there is often a notion that an outcome has only one cause; scientists, in epidemiology and other fields, recognize that every outcome has multiple causes).

But if it is the case that the caffeine sometimes does cause someone’s death — a dosage of caffeine that most of us frequently brew in our own kitchens and that you can buy pretty much anywhere that serves or sells food — how should we respond to that? Ok, forget that and just answer the much easier question: How do we respond to that? The answer, of course, is that we allow it, without restrictions on age or anything else. And, of course, as I and others have often pointed out, smoke-free nicotine is pretty similar to caffeine.

If the energy drink maker wins their case, I really hope the defense includes the observation that if the caffeine was really a cause, the poor kid was doomed. That is, even if the energy drink had been unavailable, she would have eventually gone to Starbucks. If they lose their case, it will be a legal ruling that caffeine kills via cardiovascular disease — very rarely — and it will be rather difficult to contrive a reason why nicotine should be treated any differently than this proven dangerous drug.

The second article is a commentary about the rather common use of the ADD drug Adderall as a stimulant and smart drug among college students. The commentary is kind of silly, with its Reefer Madness story of one kid’s experience (as well as the suggestion that performance enhancement in school is somehow cheating, like doping in sports). But it does effectively point out that this popular stimulant is not exactly the most benign drug in the world.

The story makes you wonder if those students would get most of the same benefit from the proven low-risk drug, nicotine. The demonization of tobacco has been so effective that those kids probably think they are making the healthier choice by using a somewhat dangerous prescription drug. In theory, it is illegal to acquire Adderall for the purpose the students are using it, whereas they could legally buy and use snus or e-cigarettes. But the reality is that within the population discussed in the article, students of major universities in the Boston area, there are greater barriers to nicotine use than there are to Adderall use.

Perhaps the tobacco would not work as well as a smart drug and many who tried it would go back to Adderall. But given what is happening, how can it possibly make sense to erect greater barriers to an almost harmless stimulant than there are for an amphetamine?

I am reminded of an observation by colleague from graduate school, as we hung out in our Boston-area basement office: If using nicotine could be made harmless, no one doing intellectual work could afford to not consume it. What neither he nor I knew at the time (though in fairness, it was still two years before Rodu’s seminal paper on the topic) was that nicotine was already available that had about the same risk profile as the coffee we were brewing at the time. So instead, other sketchier attention aids and smart drugs were preferred in our circles. And apparently they still are.

The popular myth that smoke-free products are as dangerous as smoking, so you might as well smoke, is obviously harmful to public health. But there is also a good case to be made that the myth that nicotine is worse than other attention or intellect boosting drugs may be doing plenty of harm itself.

Carl, I was thinking about quality control and e-liquids earlier this evening while reading/writing about the FDA study and the one sample out of 18 where they supposedly found some DEG. Obviously we don’t want e-liqs under the control of the FDA because, at least in its current form, the FDA would move to destroy them rather than just assure their safety. But your point about quality control opens another avenue of thought. What options are there out there for things where you might want some form of larger oversight so as to be sure you were getting the pure/quality product you’re paying for but without actual government control? I guess maybe I’m thinking in terms of generalized manufacturer’s associations or somesuch?

Tobacco Harm Reduction (THR)

THR is the public health strategy of encouraging smokers to switch to low-risk alternatives like smokeless tobacco and e-cigarettes. It is the only proven method for reducing smoking below about a fifth of the population once it becomes established. (So why would anyone be anti-THR? See the "About" page.)

The continuing scourge of [smoking]-produced disease is unlikely to yield to today’s "evidence-based" interventions. (scare quotes added) Kenneth E Warner; see post if the implications are not obvious

If someone says the sky is green, you prove that it’s actually blue, and the next day he comes back once again insisting that the sky is green, and this happens repeatedly, you eventually have to acknowledge that mannerly debate about the color of the sky just isn’t enough; you have to go meta, and talk about the fact that this guy and his friends just aren’t in the business of honest discussion. Paul Krugman

He who is merciful to the cruel will become cruel to the merciful. Ancient Midrash